Positive Results from Four Years of Administering IV Ketamine Infusions

From Kansas City Medicine, Third Quarter 2020
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By Cassie Dietrich, MD

Cassie Dietrich, MD

Depression is a common and debilitating mental disorder, with over 8% of Americans aged 20 and over suffering from the disease.(1) There are significant burdens on patients, family members and society as a whole. Suicide rates have steadily increased since 1999, from 10.5 per 100,000 to 14.2 (a 35% increase).(2) Treatment has been challenging, often consisting of multiple medications and modalities such as antidepressants, psychotherapy, transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT).

The search for a new and novel treatment for depression was underway in the 1990s as many patients were resistant to common antidepressant medications. Researchers began investigating the use of ketamine, an anesthetic that was introduced into clinical use in the 1960s. Ketamine is a useful anesthetic because it affords cardiovascular and respiratory stability while allowing effective sedation and analgesia. It can be given through multiple routes, including intravenous (IV), intramuscular (IM), oral, nasal, rectal, subcutaneous and epidural. While its mechanisms of action are multifactorial, it primarily acts as an NMDA-receptor antagonist. Ketamine is considered a “dissociative” anesthetic, potentially causing an out-of-body experience. Other side effects include nausea, vomiting, hypertension, hallucinations and a feeling of “grogginess” or drowsiness. Some patients describe feeling numb.

HISTORY OF KETAMINE FOR TREATMENT RESISTANT DEPRESSION

In 2006, researchers at the National Institute of Mental Health found that ketamine produced rapid and relatively sustained antidepressant effects in patients with treatment-resistant depression. Since then, ketamine has shown benefits in treating bipolar depression and reducing suicidal thoughts.(3) Newer studies have shown a ketamine metabolite (HNK) activates AMPA receptors essential to ketamine’s antidepressant effects.(4,5)

While not yet FDA-approved for the treatment of depression, IV ketamine has been utilized widely across the U.S. over the past decade. Protocols vary, but generally a sub-anesthetic dose of 0.5 mg/ kg infused over 40 minutes is administered to patients in a controlled setting such as a doctor’s office or hospital. Six to eight total doses are typically given over the course of several weeks, with additional infusions administered as needed for return of depression symptoms.

As IV ketamine use started to become more widespread and many articles appeared in the medical literature about its use for treatment-resistant depression, my anesthesia group decided to open a ketamine clinic in Kansas City in 2016. We formed a partnership with a psychiatry group to provide dual subspecialty expertise in the administration of this still relatively new treatment. We believed our patients would best be served by a physician anesthesiologist, an RN specializing in anesthesia care and their own psychiatrists. Our team administers the IV ketamine infusions in a monitored, yet comfortable and private, setting.

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